Republicans are divided on health care. Here’s what we know

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We have a lot to talk about, because Congress is currently bogged down on a crucial issue.

In about 22 days, much of government subsidy for health care will expire, affecting the cost and availability of insurance for at least millions of people.

However, Congress is scheduled to leave Washington in two weeks. While we suddenly have a number of plans to try to solve this problem, there is also Republican paralysis about which plan they want.

Let’s go through some basics to get started.

What expires? A set of federal subsidies that make health insurance premiums cheaper for millions of Americans under the Affordable Care Act, or Obamacare. These are called “Enhanced Premium Tax Credits,” with an abbreviation to rhyme: PTCs. They were “boosted” because they were added alongside initial subsidies during the pandemic.

How will the loss of support affect plans? KFF, a nonpartisan health policy research group, calculated that average premiums for people enrolled in enhanced subsidized coverage will more than double in 2026.

Who will lose these subsidies? Americans who earn annual incomes exceeding 400% of the federal poverty limit and who get their health insurance on the exchange will lose their subsidies if Congress does not act. The amount of support depends on income and cost levels in each state. Support will remain in place for those whose income is less than 400 percent of the poverty level.

What are the basic ideas on how to deal with this? Lawmakers are currently putting forward several plans (see below), but there are some basic concepts among the competing proposals.

• Simply expand existing subsidies.
• Expand and reform subsidies through income caps and new co-payments.
• Replace subsidies, which go to insurance companies, with direct payments to individuals, to be used to shop for health care both inside and outside the Affordable Care Act. These are commonly called HSAs or “health savings accounts.”

What do elected leaders propose to do?

Here’s a quick look at the main options and their supporters right now.

• No plan yet: President Donald Trump and House Speaker Mike Johnson
• Moving to HSAs: Senate Republican Leader John Thune
• Extending current support: Democratic leaders Chuck Schumer and Hakeem Jeffries

What specific plans are on the table?

Quite a number. These are the prominent proposals at the moment.

First, the extensions.

Democratic leaders Chuck Schumer and Hakeem Jeffries have proposed extending ACA benefits for three years. Photography by Evelyn Hochstein/Reuters

Moreno Collins plan. From Senators Bernie Moreno, Republican of Ohio, and Susan Collins, Republican of Maine. This is not a complete draft law, but rather a framework.

• Extension of enhanced support? Yes. For two years and then finish it.
• Income limit? Yes. It would add a household income limit of $200,000 and require a minimum payment of $25 per month.

“CommonGround” plan. Of about 35 Republicans and Democrats in the House, led by Reps. Gene Keegans, R-Va., and Josh Gottheimer, R-Del. It’s another frame.

• Extension of enhanced support? Yes. One year.
• Income limit? Yes. This plan would phase out benefits for those with incomes between 600% and 1,000% of the poverty level. This would extend the open enrollment period until March 19, 2026. It would also increase votes on larger reforms, including HSA accounts.

“Bipartisan Health Insurance Affordability Act.” Of eight House Republicans and Democrats, led by Reps. Brian Fitzpatrick, R-Pa., and Tom Suozzi, D-N.Y. This is the actual bill, passed Tuesday.

• Extension of enhanced support? Yes. Two years.
• Income limit? Yes. At 700 percent of the poverty level.

Democrats’ three-party plan. Congressional Democrats, led by Leaders Schumer and Jeffries, support a relatively simple plan.

• Extension of enhanced support? Yes. Three years.
• Income limit? no.

And now, HSA reformers.

Sen. Bill Cassidy, R-La., listens to testimony during a Senate hearing on health care costs in November. Photography by Jonathan Ernst/Reuters

Crapo Cassidy’s plan. From Sens. Mike Crapo, R-Idaho, and Bill Cassidy, R-Los Angeles. This is an official bill entitled the “Patient Health Care Freedom Act.”

• Extension of enhanced support? Yes, but it changes it dramatically.
• Income limit? Yes. 700 percent of the poverty level.
• HSA replacement? Yes. Subsidies will be placed in HSA accounts, which will vary by age: $1,000 for people ages 18 to 49 and $1,500 for those ages 50 to 65.

Scott’s plan. From Senator Rick Scott, Republican of Florida. This is also an official bill called the “More Affordable Care Act.”

• Extension of enhanced support? no.
• HSA replacement? Yes. Scott will keep the remaining benefits, which will revert to the ACA’s original limit of 400 percent of the poverty level. These individuals will receive benefits into the Trump Health Freedom Account, an HSA-style account, which they can use to pay insurance premiums or other medical costs.

What’s happening now

The Senate will hold two votes on Thursday: one on a three-year Democratic extension and the other on a plan from Senate Republicans (the Crapo-Cassidy plan).

Neither is expected to pass.

It is not clear what, if anything, the House and White House might propose.

It will be worth watching this week to see whether either Democrats or Republicans vote with the other side in the Senate. But then the next steps are not clear.

This leaves only a few days until support runs out, with Republicans scrambling.

Bipartisan groups in the House may try to file a recall petition, which is one way to get around the leadership caucus. But it’s not clear they can attract the 218 signatures they need for any single idea.

As we say, stay tuned.